megan king, wagga health service: establishing a consultant led 7 day acute surgical unit: improving...
DESCRIPTION
Megan King, Perioperative Nurse Manager, Wagga Wagga Health Service delivered this presentation at the inaugural Developing a 7 Day Health Service Conference. By moving to whole of system 7 day a week health delivery, public and private hospitals, social care and support services, and healthcare organisations can improve patient care, safety, and outcomes. The event examined different models for offering a 7 day a week patient-focused service. For more information about the annual event, please visit the conference website http://www.healthcareconferences.com.au/sevendayhealth.TRANSCRIPT
Establishing an Acute Surgical Unit in a Rural
Area
Wagga Wagga Health Service
November 13 Sherylle Sheehy ASU CNC, Megan King Perioperative NM
Wagga Wagga is the largest inland city in NSW and one of Australia’s leading regional cities with a population over 61,000 (06/2008 census).
Wagga is the local Wiradjuri aboriginal word for crow and to create the plural, the Wiradjuri repeat the word. Thus Wagga Wagga translates as 'the place of many crows'.
Wagga Wagga Base Hospital is a rural referral hospital and the major acute care provider and referral hospital for the Murrumbidgee Local Health Network ... Wagga Wagga Base Hospital has 237 'beds' including 209 overnight inpatient beds and 28 ambulatory treatment places. (Wagga Wagga Hospital Clinical Services plan 08/2006)
November 13 Sherylle Sheehy ASU CNC, Megan King Perioperative NM
General – 8 General Surgeons Orthopaedics – 6 Orthopaedic surgeons - 1 elective
only Urology – 3 Urologists ENT – 2 ENT Surgeons Vascular – 2 Vascular Surgeons Ophthalmology – 3 Ophthalmologists O&G – 1 O&G + locum service 2 Gynaecologists
elective only Paediatrics – 1 x Paediatric Surgeon Endoscopy – 2 Physicians, 2 Respiratory Physicians Dental ECT Vascular Access service
November 13 Sherylle Sheehy ASU CNC, Megan King Perioperative NM
Types of Surgery
November 13 Sherylle Sheehy ASU CNC, Megan King Perioperative NM
Historical Approach to General Surgery Presentations
Surgeon: On call for 24hr period Normal public/private operating list Normal consulting in rooms Not always available during hours
Theatre: Designated Emergency sessions often unable to be utilised or on occasions utilised for elective surgery Emergency Cases added to elective lists surgeon Emergency cases commenced after 1800
November 13 Sherylle Sheehy ASU CNC, Megan King Perioperative NM
Issues
• After hours operating , escalating overtime of staff –
medical, nursing and ORA’s
• Cancellation of elective patients to accommodate
emergency cases
• Increase in diagnostic tests
• Delay in Surgical Review of ED presentation
• Delay in consults on inpatients
Sherylle Sheehy ASU CNC, Megan King Perioperative NM
Commencing an ASU
The ASU model of care was driven by the surgeons
After consultation with WWBH Executive, funding for the
model was sourced from MOH.
The surgeons as a group proposed how they would do their on
call roster: decided 7 days on, full handover to next Surgeon,
Friday to Friday.
A Registrar was to be allocated to ASU
Average 35 – 40% of all operations at WWBH are emergencies
Allocated Ortho Trauma and Emergency sessions
Ortho Trauma: almost every day of month
Emergency: Every afternoon 1330 – 1730 (ASU), then overnight and weekends
November 13 Sherylle Sheehy ASU CNC, Megan King Perioperative NM
Emergency Surgery
Emergency Sessional Allocation
November 13 Sherylle Sheehy ASU CNC, Megan King Perioperative NM
THEATRE TIME MON TUE WED THU FRI SAT SUN
1 AM Trauma Trauma
Trauma
PM Trauma Trauma Trauma Trauma Trauma Trauma
2 AM Emergency Emergency
PM ASU ASU ASU ASU ASU Emergency Emergency
3 AM
PM
4 AM
PM
5 AM
PM
ENDO AM
PM Evening /
Overnight Emergency Emergency Emergency Emergency Emergency Emergency Emergency
Getting Logistics Right
November 13 Sherylle Sheehy ASU CNC, Megan King Perioperative NM
• Commence a Steering Committee with weekly meetings
• Service Development Application
• Business rules
• Contracts for Doctors
• How the Doctors will be paid
• Identifying ASU patients in IPM to get reports
• Position descriptions for CNC, Clerical, and Data Manager
• Office space and Office fit outs
• How will Private patients be managed. -
Steering Committee
November 13 Sherylle Sheehy ASU CNC, Megan King Perioperative NM
• Chaired by WWHS GM
• Initially DM, DMS, DONM, Theatre Manager, Client Services
Manager, Business Manager
• Meet weekly
• Later included Director of Emergency
• Separate meeting with WWHS Executive and Surgeons
Service Development Application
November 13 Sherylle Sheehy ASU CNC, Megan King Perioperative NM
• Included cost modelling
• Designed around cost benefits: • Reduced overtime • Reduced LOS • Reduced pathology and imaging costs
• Staffed by:
• CNC • Clerical Assistance • Data Manager
Business Rules
November 13 Sherylle Sheehy ASU CNC, Megan King Perioperative NM
• Developed by DMS in conjunction with Surgeons • WWHS expectations of how ASU will function • Includes rules on: Roster provision including Registrar allocation to ASU Consults and ward rounds Handover Allocated Emergency Operating time Transfer from Emergency department Supervision Clinics Protocols and pathways Attending Rooms and Private hospital while on call Timely Accounting
Surgeon Contracts & Payment
November 13 Sherylle Sheehy ASU CNC, Megan King Perioperative NM
• Special permission for a non standard contract for Surgeons
• Surgeons submit separate claim to Normal VMO claim for ASU
Identifying ASU Patients in iPM
November 13 Sherylle Sheehy ASU CNC, Megan King Perioperative NM
• Set up a new sub specialty for each surgeon in IPM
• Eg ‘Dr Harrison’ specialties of ‘General Surgery’ or ‘Acute Surgical’
• Allows printing a report for where patients are as there is no specific ward for ASU patients
Position Descriptions
November 13 Sherylle Sheehy ASU CNC, Megan King Perioperative NM
• Longer than we thought, had to go through Grading
Committees
• Easily recruited to CNC
• Clerical and Data Manager took longer to recruit
Office Space and Fit Out
November 13 Sherylle Sheehy ASU CNC, Megan King Perioperative NM
• Big problem as very limited space at WWBH
• GM rearranged location of WWBH Staff to allow ASU
to go into a newly built demountable office located in
between A&E and Theatre
• Begged, borrowed and stole office desks
• Purchased new chairs, computers, Printer/fax/
photocopier machine
• 4 desk spaces and computers (CNC, Clerical, Registrar and Intern)
• Worked with Surgeons and PLO’s to develop a patient brochure explaining the ASU including how it affects private patients
• Surgeons historically have preferred to keep any emergency patients at Base Hospital for a variety of reasons
• Decisions about which patients can be transferred to Private Hospital is determined on a case by case basis.
November 13 Sherylle Sheehy ASU CNC, Megan King Perioperative NM
Private Patients
Sherylle Sheehy ASU CNC, Megan King Perioperative NM
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
% 08:00 - 18:00 % 18:00 - 22:00 % 22:00 - 08:00
WWBH % General Surgery emergency cases - grouped by Case Start Time.
WWBH % General Surgery emergency cases - grouped by Case Start Time.
Data Source:- SurgiNet custom report - (all Fields, All Records) extraction of data by Time of Day ranges (EXCEL)
Sherylle Sheehy ASU CNC, Megan King Perioperative NM Data Source:- SurgiNet custom report - (all Fields, All Records) EXCEL sum / count of selected times / records by month
Sherylle Sheehy ASU CNC, Megan King Perioperative NM
Data Sources:- SurgiNet custom report - (all Fields, All Records) CORVU staff payroll report EXCEL sum / counts of selected times / records by month
Sherylle Sheehy ASU CNC, Megan King Perioperative NM Data Source:- SurgiNet SN027B EXCEL sum of times for selected records by month
Sherylle Sheehy ASU CNC, Megan King Perioperative NM
Data Source:- SurgiNet SN027B EXCEL % of cases by specialty and month
Sherylle Sheehy ASU CNC, Megan King Perioperative NM Data Sources:- SurgiNet custom report - (all Fields, All Records) EXCEL counts of selected times / records by month
Sherylle Sheehy ASU CNC, Megan King Perioperative NM Data Source:- Pathology service provider invoice records from LHD Finance office.
Sherylle Sheehy ASU CNC, Megan King Perioperative NM
Data Source:- SurgiNet custom report - (all Fields, All Records) then manual selection of category for each procedure
Ward Round Checklist
DVT program
Cholecystectomy Case Delay Audit.
Sherylle Sheehy ASU CNC, Megan King Perioperative NM
Quality improvement projects
Sherylle Sheehy ASU CNC, Megan King Perioperative NM
Ward Round Checklist
WARD ROUND CHECK LIST
EXAMINATION MANAGEMENT
Hands washed (before & after) Results (checked)
Wounds /Patient examined) Mobility (maximised)
Lines & Tubes (site & need reviewed) Diet (maximised)
Bowels (treated if BNO > 24 hr) Allied health (consulted)
CHART REVIEW COMMUNICATION
Vitals (checked) Nurse on round (present)
DVT prophylaxis / TEDS (charted + given) EDD :
Analgesia (adequate)
Medications (new/routine)
Fluids (U/O & Balance checked) Date: ___________ Signed: ________________
Sherylle Sheehy ASU CNC, Megan King Perioperative NM
Ward Round Sticker
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
May Jun Jul Aug Sept Oct
%ASU Patients with Discharge Plan (Ward Round Checklist Sticker introduced late May/early
June)
Ward round sticker introduced
Data Source:- ASU Internal Audit
Sherylle Sheehy ASU CNC, Megan King Perioperative NM
Roadblocks Limited consultation with all key stakeholders in planning phase Admission process in PAS System couldn’t identify the patients in
ASU Recruitment of Clerical Support Clerical Support commenced 25th June, 2012
• Inability to recruit Data Manager Commenced 20th August, 2012
• Delays in Database Construction via LHN IT • Development of Protocols for Standardise Patient Care • Workload of ASU Medical Team – JMO’s – 25 – 30 patients each day • Appropriate Outpatient Clinic Time • Accredited Registrars access to Surgical Procedures – not meeting
requirements • Some KPIs unable to be easily measured eg Pathology and Imaging
costs
Sherylle Sheehy ASU CNC
Margaret Fifield Relieving ASU CNC
Greg Atkinson ASU Data Manager
Michelle Sleep (Previous WWHS GM)
Sherylle Sheehy ASU CNC, Megan King Perioperative NM
Acknowledgements